Culture is overly simplified

In the NHS, significant focus is given to ‘creating the right culture’ and it is described as something we ought to ‘have’. In fact, cultures are multiple in organisations and behaviour has complex origins, and can relate to both reality and perception. Culture is layered, complex, and deeply social.

The challenge for many years now, rightly posed by the powers that be to those providing health and care services at a local level (but not necessarily a “north star” for themselves) has been to foster a culture focused on learning and improvement, where all staff feel supported and confident to be open and candid. This is of enormous importance and leaders at all levels have an essential role to play. But it is fiendishly difficult, and it might help if this was better recognised. In fact, the importance and challenge of speaking up has been a repeated finding in care inquiries going back to 1969.

What could make a difference?

Shaping culture requires more than will and the right attitude, and can’t rely mostly on the discretionary effort of staff if sustained improvement is to be achieved. I’m sure most people have noticed that culture change is different from procedural implementation, whereas it has felt over the years that there is an apparent assumption that a policy directive can affect a change in culture.

I’ve also noticed a lack of balance in emphasis between the ‘what’ organisations are to do and the ‘how’ this can and should be achieved. For example, what is the best way to address the rare pockets of extremely negative behaviours in individual staff members that can have a disproportionate impact? Should this approach change when there are struggles to recruit to certain specialised roles amid gaps in the workforce and pressure to retain provision of services? What takes priority, shaping the culture of tomorrow or providing services today?

The risk is that ambitions for improving culture have become akin to jargon (“create a just culture”). What this actually means for the day to day reality for people in different roles should be an ongoing conversation, mostly focused on listening – and involving those who receive care too. As we get close to the new 10 Year Health Plan being published, and as a new structure continues to take shape, it’d be worth remembering “the behaviours of national bodies largely shape what local leaderships do or don’t do”.

Would recognition and a restorative approach help with a culture reset?

Cultures evolve and are living entities rather that a single product we can pick off the shelf for an organisation or system and launched anew. With that in mind, what needs to be true to help the NHS get somewhere new? I’d like to see the following guide policy development and implementation around how we make the coming 10 Year Health Plan a reality, including the expected national Quality Strategy (to come later this year):

• Let’s stop “culture” being set up as the problem and the solution; it has been weaponised and over simplified. Recognising that healthcare is incredibly complex means recognising that it can be a difficult work environment. To help the whole system perform well, we need to help all individuals to work well.  
  

• Focus on creating the conditions that help people do the work of health and social care safely, effectively and with agency, pride and joy – “There is no dispute about the preconditions for high quality, safe care: funding, staff, training, buildings, equipment, and other infrastructure”. With tight fiscal constraints, that means an ongoing conversation around what helps create value, and action taken around what hinders.
  

• What tends to be less recognised is that this is emotional as well as practical. The work of health and social care - meeting other’s needs – should be done without undue burden and cost to those who care. Right now, there is a need to build energy and hope for a reformed system. From conversations I’ve had with staff at different levels and in different parts of the system, honest exploration of what matters to them, and recognition of what it cost to work through the pandemic and onto recovery, without a break (or reward – and no, the badge doesn’t count) may help draw a line under the last decade and help build hope and energy – and importantly, trust - that different is possible and it’s worth sticking it out.
  

• In the world of safety, one approach to encouraging a just and restorative culture is to ask “who is hurt, what do they need, whose responsibility is it to meet that need?”. This could bring about a relationship reset – which is important when we talk about changing cultures. It could help build a better understanding between those with power and those on the receiving end of it, including encouraging an honest conversation around why racism, bullying and other attitudes and behaviours persist. Starkly bad staff survey results are normalised in the NHS.
  

• Hierarchy and other contributing factors are recognised, but I’d say there is very little containment of the anxiety generated by emotional labour or fixing of the frustrations and challenges in day-to-day work. This is no excuse for terrible behaviour but it can’t help. If national, regional and local leaders don’t demonstrate they care, through owning their own role in generating fear and defensive reactions, and by reducing the worries, fear and irritations by prioritising practical support and investment in day to day work, then it arguably robs them of the moral high-ground when it comes to setting standards for others to meet on culture and behaviour. It also makes no sense not to do this if you know it is a degraded and difficult system to work in, wasting time, energy, resource, yet are seeking better value from the money being spent.
  

• It would also help if there was greater clarity on the role and behaviours of each level of the system in relation to fostering the desired cultures, with consistency in good times and bad. The work around “The CQC Way” under Sir Julian Hartley is showing this is possible – there is an intention to implement shared values and behavioural expectations for both CQC staff and regulated organisations. This could set a new bar.
  

• At a national level, organisations with a bearing on the system could also look more closely at how together they can be greater than the sum of their parts when it comes to supporting the system to achieve the outcomes we all want to see. This means ensuring that policy initiatives are better co-ordinated and evidence-based, rather than developed in silos which can result in conflicts and tensions in implementation locally. It means NHS England or other arms-length bodies and DHSC proactively assessing different departments asks to the service, in respect to the trade-offs likely in practice and in how they may affect culture and relationships. For instance, addressing conflict between narratives rather than ignoring it. Unlike what we saw during and after the pandemic when trusts were asked to ensure staff were able to rest, whilst also meeting considerable expectations for speedy elective recovery.
  

With reform comes a need to mobilise change. Relationships, attitudes, behaviours, norms – all facets of culture – need to continue to be part of the conversation at every level over the next 10 years to support that. I hope we move on from setting standards without making it easier to meet them, and culture is instead seen as a collective endeavour. I have hope this is where we are heading now - with the tone and signals in Wes Streeting's Confed speech - as he quoted from a Chief Executive this week, everyone needs to feel that “I can see light at the end of the tunnel and I’m finally convinced it’s not an oncoming train about to hit me!”.